Estimated reading time at 200 wpm: 9 minutes

This AI Assisted summary is fully traceable to the source document, ensuring transparency and accountability. Nobody in their right mind has the time to read all of 302 pages. Therefore, AI was used to assist. There may be errors in this publication. Readers must check all page number references and meanings extracted for accuracy and relevance. The full report (302 pages) is at https://media.cuh.nhs.uk/documents/Verita_report_-_October_2025_1.pdf

Some may be wondering, “What has this got to do with psychiatry?” I am deeply sorry for those types, as well as their back-slapping colleagues.

Table of Contents

• Initial Summary
• 1. What Went Wrong?
• 2. Why It Went Wrong
• 3. Systemic Failures
• 4. Accountable Leaders
• 5. Lessons Learned
• 6. Other Key Takeaways
• Conclusion

Initial Summary

This report is not merely an account of one surgeon’s failings—it is a stark, systemic warning to the entire UK healthcare system.

Cambridge University Hospitals NHS Foundation Trust commissioned Verita to investigate how a serious and prolonged risk to paediatric patients went undetected for nearly a decade. The findings reveal a catastrophic failure of clinical governance: a senior consultant, Ms Stohr, continued operating on vulnerable children with demonstrable technical deficiencies, while the Trust’s leadership, despite multiple red flags, failed to act.

The pivotal moment came in 2016, when an external review by an expert paediatric orthopaedic surgeon, Mr Hill, clearly identified specific, actionable concerns about Ms Stohr’s surgical technique and decision-making. Yet, rather than triggering immediate, structured support and oversight, the report was misinterpreted, its critical recommendations diluted, and its findings confined to a small circle. The message delivered to Ms Stohr and her colleagues was not one of concern requiring intervention, but of exoneration. The result? A culture of silence, a fragmented system of oversight, and seven years of unchallenged practice that harmed children.

This case is profoundly relevant because it exposes the lethal consequences of three endemic NHS weaknesses: the failure to “join the dots” between hard data and “soft signals” (like workload stress or fractured team dynamics); the absence of clear accountability for clinical performance; and the corrosive impact of a culture where concerns are dismissed as interpersonal conflict rather than patient safety issues.

For UK doctors, it is a sobering reminder that autonomy must be balanced with robust, visible peer review and governance—not just in theory, but in daily practice. For health service managers and executives, it is an urgent call to action: systems designed to protect patients are only as strong as the leadership that enforces them. This report is a blueprint for change—not just for paediatric orthopaedics, but for every specialty in the NHS where low volume, high complexity care is delivered. The question it forces us to ask is not “How did this happen here?”, but “How many other such failures are we silently tolerating?”

1. What Went Wrong?

The fundamental failure was the misinterpretation and miscommunication of Mr. Hill’s 2016 external review [p. 6]. Despite detailed clinical concerns identified in 11 of Ms. Stohr’s cases—including technical errors in pelvic and femoral osteotomies and the absence of post-operative 3D imaging—Deputy Medical Director A (DMD A) summarised the report as finding “no significant concerns about Kuldeep’s practice” [p. 79]. This misrepresentation led to no restrictions on her surgical practice, no structured support, and no formal action plan. The findings were not shared beyond a small group, and no duty of candour was exercised with affected families [p. 107–108]. As a result, Ms. Stohr continued operating for nearly a decade with unaddressed deficiencies, causing prolonged harm to paediatric orthopaedic patients [p. 286].

2. Why It Went Wrong

• Misinterpretation by DMD A: He focused on the report’s summary paragraph, overlooking its specific clinical criticisms [p. 68]. He did not consult Mr. Hill for clarification [p. 69], nor did he share the full report with a senior paediatric orthopaedic surgeon for expert interpretation [p. 86].
• Fragmented Governance: Responsibility for action was ambiguously handed from the Medical Director’s Office (which commissioned the review) to Division E (which managed the service), with no clear ownership [p. 90–91].
• Cultural Failures: A “blame culture” discouraged speaking up; Consultant A felt silenced after raising concerns and was told his concerns were dismissed [p. 81]. Organisational complacency led to the report being treated as an interpersonal issue rather than a clinical one [p. 100].
• Lack of Clinical Expertise in Oversight: DMD A (a nephrologist) and the Director of Division E (a paediatrician) lacked orthopaedic expertise to interpret surgical technical critiques [p. 78].

3. Systemic Failures

• No Accountability: No individual was assigned to track implementation of Mr. Hill’s recommendations [p. 93].
• Poor Data Integration: Hard data (Datix incidents, audit) and “soft signals” (appraisals, OH reports, workload stress) were siloed and never triangulated [p. 161].
• Ineffective MDT: The MDT established after the review was voluntary, poorly documented, and lacked administrative or operational management input [p. 175–177].
• No Follow-up Mechanism: No review of Ms. Stohr’s practice was scheduled after 6–12 months to assess improvement [p. 120].
• Failure to Record Harm: None of the 11 cases flagged by Mr. Hill were recorded as patient safety incidents in Datix or on the risk register [p. 107–108].
• Silenced Whistleblowing: Consultant A’s prior concerns were dismissed, and he was discouraged from raising further issues, creating a culture of fear [p. 81–82].

4. Accountable Leaders

• Deputy Medical Director A: Primary architect of the miscommunication; misrepresented findings to Ms. Stohr, Consultant A, and Division E [p. 79, 86].
• Director of Division E: Accepted the mischaracterisation of the report and took no action beyond initiating an MDT [p. 105–106].
• Medical Director (Dr. Jag Ahluwalia): Was unaware of the report’s content; failed to provide oversight [p. 49].
• Chief Medical Officer (Dr. Ashley Shaw): Did not see the Hill report until 2024 and was unaware of its existence during his tenure [p. 261].
• Chief Executive Officer (Mr. Roland Sinker): Unaware of the 2016 review until 2024 [p. 260].
• Deputy Medical Director B: Was aware of Ms. Stohr’s behavioural issues in 2023–2024 but had not read the Hill report before 2025 [p. 264].

5. Lessons Learned

• External reviews must be interpreted by clinical experts: DMD A should have consulted Mr. Hill and a senior orthopaedic surgeon before summarising findings [p. 86–87].
• Clear accountability is non-negotiable: A named individual must own implementation of review recommendations [p. 99].
• Join the dots: Systems must integrate hard data (Datix, audits) with soft signals (appraisals, OH referrals, workload) to form a holistic risk profile [p. 161].
• Mandatory, structured MDTs: MDTs must be mandatory, include all disciplines, document decisions, and be supported administratively [p. 177, 182].
• Duty of Candour must be enforced: Patient harm identified in reviews must be disclosed to families immediately [p. 108].
• Leadership visibility: Senior leaders must engage directly with frontline teams to understand culture and risk [p. 271].
• Support for “second victims”: Clinicians under review need psychological and professional support, not just punishment [p. 118, 237].
• Transparency over secrecy: Findings from external reviews must be shared widely within the specialty, not restricted to a few [p. 94–95].

6. Other Key Takeaways

• Ms. Stohr’s Agency: Despite the system’s failure, she independently sought peer feedback at Norfolk & Norwich Hospital and attended regional MDTs to improve [p. 114–117].
• Nuffield Hospital Oversight: CUH failed to inform Nuffield Hospital (where Ms. Stohr practised privately) of the 2016 review or subsequent concerns in 2024–2025, breaching the IHPN Medical Practitioners Assurance Framework [p. 268–269].
• Cultural Resistance: There was a systemic reluctance to learn from external reviews (“basking in reflected glory”) and a tendency to neutralise uncomfortable findings [p. 100].
• Workload as a Red Flag: Ms. Stohr’s unsustainable workload and stress were documented in appraisals (2017/18) and OH reports (2015, 2024), yet no action was taken [p. 132, 146].
• Dual Operating: The absence of mandatory dual consultant operating for complex cases—a recommendation in the Hill report—was a critical missed safeguard [p. 191–192, 202].

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Conclusion

This report is not merely about one clinician’s failings—it is a damning indictment of a system that knew, for nearly a decade, that something was wrong but failed to act. The 2016 Hill report was a clear, actionable early warning. Mismanagement was the pivotal missed opportunity. The recommendations provided here are not aspirational—they are essential, non-negotiable steps to prevent recurrence.

This report is not an isolated failure—it is a devastatingly familiar pattern. It echoes the same mismanagement, the same institutional blindness, the same tragic disconnect between systems and safety that we’ve seen in countless other NHS investigations: from Mid Staffordshire to Morecambe Bay, from the Savile scandal to the Ian Paterson case.

The core failure here is not just technical—it’s cultural. The Trust had multiple, clear warning signs: a deeply strained relationship between consultants, a consultant with an unsustainable workload and documented stress, an external review that identified specific, actionable clinical concerns, and a senior manager who misinterpreted and misrepresented the findings to provide reassurance instead of action. Yet, the system did not react. It did not connect the dots. It did not protect patients.

The fact that Ms. Stohr herself sought help, attended MDTs elsewhere, and tried to improve—while the organisation remained silent and passive—makes it even more painful. She was a “second victim” of the system’s failure, not its sole cause.

And then, the silence persisted for nearly a decade. The Hill report was not buried—it was ignored, diluted, and miscommunicated. And when the same concerns resurfaced in 2024, the response was shock, not recognition. The same people who failed in 2016 were still in charge in 2024. The same systems that failed then were still in place.

This isn’t just about one consultant or one department. It’s about a healthcare system that has learned to tolerate “good enough” governance, to confuse process with performance, and to mistake silence for stability.

The recommendations in this report are not new. They are the same ones we’ve seen before. What’s different this time is the sheer scale of the harm—children harmed, families betrayed, and colleagues silenced—and the fact that the Trust knew enough, in 2016, to prevent it.

The real question isn’t “what went wrong?”—we’ve seen that too many times.

The real question is: When will the NHS stop treating these reports as lessons to be read, and start treating them as alarms to be acted on—immediately, relentlessly, and without exception?

Until that happens, we will keep reading the same story, written in different names, in different hospitals, with the same devastating outcome.

“The only thing that is necessary for the triumph of evil is for good men to do nothing.” — Edmund Burke
In this case, good men and women did act—Consultant A, Mr. Hill, Ms. Stohr herself—but the system failed them.

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References
All page numbers cited above correspond to the footer page numbers in the original Verita report, An independent investigation into potential missed opportunities for identification and avoidance of possible harm to paediatric orthopaedic patients at Cambridge University Hospitals NHS Foundation Trust, October 2025.